Avamere Rehabilitation Of Eugene

Based on observation, interview, and record review it was determined the facility failed to provide care-planned eating assistance for 1 of 4 sampled residents (#14) reviewed for nutrition. This placed residents at risk for reduced nutritional intake and decline in positioning. Findings include:Resident 14 was admitted to the facility in 11/2025 with diagnoses including rheumatoid arthritis, dementia, and unspecified deformity of the fingers.A 11/11/25 admission MDS indicated Resident 14's BIMS score was nine which indicated she/he had moderately impaired cognition. Resident 14 required setup and cleanup assistance for eating.A 11/6/25 Care Plan indicated Resident 14 required setup assistance for eating. Observations on 1/12/26 from 12:12 PM to 1:10 PM revealed Resident 14 arrived in the facility main dining room for lunch at 12:30 PM. Resident 14 received her/his meal at 12:42 PM. Resident 14 was seated in a wheelchair at a dining table, and the meal was not within her/his reach. Resident 14 was observed leaning forward in the chair two to three times, bringing her/his trunk closer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review it was determined the facility failed to provide ADL care to dependent residents for 1 of 1 sampled resident (#11) reviewed for ADLs. This placed residents at risk for lack of nail care. Findings include: Resident 11 was admitted to the facility in 1/2024 with diagnoses including below the knee amputation, legal blindness, and diabetes.Resident 11's 1/29/26 Annual MDS indicated the resident had moderate cognitive impairment.The 2/1/24 care plan indicated Resident 11 had ADL self-care performance related to legal blindness, heart failure, and limited mobility, required one staff member to set-up and offer location of items on her/his overbed table and plate, and was able to feed and drink independently. Resident 11 preferred to eat with her/his hands.The 12/2025 TAR indicated Resident 11's nails were trimmed on 12/24/25.The 12/2025 TAR indicated diabetic nail care weekly every evening shift every Wednesday for diabetes.The 1/2026 task document indicated on 1/8/26 Resident 11 had a shower.On 1/12/26 at 10:34 AM, 1/13/26, and 1/14/26…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review it was determined the facility failed to ensure staff provided two-person assistance when transferring a resident and failed to ensure a environment remained free from accident hazards for 2 of 4 sampled resident (#s 31 and 42) reviewed for accidents. This placed residents at risk for accidents. Findings include: Resident 31 was admitted to the facility in 12/2025 with diagnoses including dementia. A 12/5/25 care plan indicated Resident 31 was at risk for falls and padded fall mats were to be placed at both sides of the bed when Resident 31 was in bed. On 1/13/26 at 9:27 AM, Resident 31 was observed in bed without a fall mat on the left side of her/his bed. On 1/14/26 at 9:01 AM, Resident 31 was observed in bed with the left side of the bed fall mat on the floor, but not next to Resident 31's bed. On 1/14/26 at 2:43 PM, Resident 31 was observed in bed without a fall mat on the left side of her/his bed. On 1/14/26 at 2:45 PM, Staff 4 (CNA) stated Resident 31 was at risk for falls and was to have fall mats on the floor next to her/his…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review it was determined the facility failed to provide specialized rehabilitation services for 1 of 2 sampled residents (#31) reviewed for positioning. This placed residents at risk for decline in physical ability. Findings include:Resident 31 was admitted in 12/2025 with diagnoses including dysphagia (difficulty swallowing) and dementia.A review of Resident 31's 12/14/25 hospital discharge summary indicated Resident 31 had orders for PT, OT, and ST.A review of Resident 31's medical record revealed no evidence of PT, OT, or ST documentation since 12/14/25.On 1/12/26 at 12:21 PM, Resident 31 was observed up in a wheelchair that was tilted back, without a headrest, and without footrests. Resident 31's head was observed to hang off the back of the wheelchair without support and Resident 31's feet were not supported.On 1/16/26 at 10:26 AM Staff 5 (LPN Resident Care Manager) stated Resident 31 was re-admitted to the facility on an altered textured diet due to dysphagia, but stated Resident 31 was not re-admitted with orders for PT, OT, or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to ensure a resident received wound care according to physician orders for 1 of 3 sampled residents (#102) reviewed for wound care. This placed residents at risk for worsening wounds or infection. Findings include: Resident 102 was admitted to the facility in 3/2025, with diagnoses including an open fracture of the left lower leg with a deep incisional surgical site and diabetes. Resident 102's Hospital Discharge Instruction Orders dated 3/15/25 revealed staff were to make a follow-up appointment with the surgeon in two weeks and provide the following surgical wound care instructions: -Honeycomb dressing on for 7 days. Change if saturated more than 50%. Leave off after 7 days. Resident may shower. -Call MD for excessive drainage. -OK to remove staples two weeks after surgery if patient is still present in facility. -Apply ice to affected area as needed (typically 20 minutes every 2-3 hours) to control swelling and pain. -If splint or cast in place please keep clean and dry until first post visit. Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to ensure interventions to prevent a resident's elopement were in place for 1 of 3 sampled residents (#315) reviewed for accidents. This placed residents at risk for lack of a safe enviroment. Findings include: Resident 315 admitted to the facility in 5/2024 with diagnoses including Parkinson's disease (disease of the nervous system) and repeat falls. A 9/15/24 revised care plan indicated Resident 315 was an elopement risk with impaired safety awareness, she/he was not to leave the facility unattended and staff were to determine the reason for her/him wanting to leave the facility with pleasant diversions offered. A 9/16/24 Nursing Care Note indicated Resident 315 was observed exiting the facility out the back door (close to her/his room) by Staff 10 (CNA) and two staff followed the resident. Resident 315 came back into the building with assistance by Staff 3 (Resident Care Manager-LPN). Resident 315 acknowledged she/he attempted to leave the building (unattended) and 15-minute checks were implemented. A…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to update care plans for 4 of 11 sampled residents (#s 4, 15, 18, and 48) reviewed for UTIs, medications, ADLs, and accidents. This placed residents at risk for unmet care needs. Findings include: 1. Resident 4 was admitted to the facility in 1/2024 with a diagnosis of MS (multiple sclerosis: lack of electrical impulses from the brain to the body creating impaired body functions). Resident 4's care plan initiated on 5/7/24 revealed her/his urinary catheter was to be flushed (instilling a sterile solution into the catheter to ensure the tubing does not clog) three times per week. A 7/20/24 Progress Note revealed Resident 4's urology (specialized in urinary systems i.e. bladder, kidneys etc.) clinic sent physician orders to flush her/his urinary catheter (medical tubing inserted in the bladder to drain urine) one to two times each day. On 8/2/24 at 10:59 AM Staff 23 (LPN Resident Care Manager) stated when new orders were received for residents, the floor nurses were to update care plans. Staff 23 stated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review it was determined the facility failed to follow-up with pain medication, perform neuro checks, follow physician orders and perform wound assessments for 5 of 10 sampled residents (#s 4, 15, 42, 163, and 165) reviewed for pain, accidents, UTI, and hospice. This placed residents at risk for unmet care needs. Findings include: 1. Resident 4 was admitted to the facility in 1/2024 with a diagnosis of MS ((multiple sclerosis: lack of electrical impulses from the brain to the body creating impaired body functions). A 7/2024 TAR revealed when Resident 4's urinary catheter (medical tubing inserted in the bladder to drain urine) was replaced, staff were to obtain a UA and culture (identified orginisms which caused a UTI). A 7/18/24 Progress Note revealed Resident 4 reported abdominal pain and there was no urine in the resident's catheter tubing or catheter urine collection bag. Staff replaced the existing catheter with a new sterile catheter and obtained a urine sample. A 7/18/24 Lab Results Report revealed the UA was not completed because…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to ensure CNAs received 12 hours of training for 3 of 5 sampled staff (#s 3, 4, and 7) reviewed for staffing. Findings include: Review of CNA training records revealed: -Staff 3 was hired in 7/2016 and did not have 12 hours of training for the last one year. -Staff 4 was hired in 7/2022 and did not have 12 hours of training for the last one year. -Staff 7 was hired in 9/2021 and did not have 12 hours of training for the last one year. On 8/1/24 at 8:30 AM Staff 2 (DNS) verified Staff 3, 4, and 7 did not have 12 hours of training in the last year.

Based on interview and record review it was determined the facility failed to inform residents of the risks and benefits of psychotropic medication use for 1 of 5 sampled resident (#12) reviewed for medications. This placed residents at risk for being uniformed. Findings include: Resident 12 admitted to the facility in 2024 with diagnoses including anxiety disorder and depression. A review a 7/18/24 physician order revealed Resident 12 received Lexapro (antidepressant) daily. A review of the medical record revealed no risk and benefit information for Lexapro. On 8/5/24 at 10:26 AM Staff 2 (DNS) verified the risk and benefit information was not reviewed with Resident 12.

Based on observation, interview, and record review it was determined the facility failed to assess a resident's ability to self-administer medications for 1 of 1 sampled resident (#11) reviewed for respiratory care. This placed residents at risk for improper medication administration. Findings include: Resident 11 was admitted to the facility in 8/2014 with diagnoses including COPD (lung disease). On 7/31/24 at 10:57 AM Resident 11 was sitting up in bed with two inhaler medications for COPD on the bedside table. Resident 11 explained these medications were used to help her/his breathing. No assessment was found in the medical record for self-administration of medications for Resident 11. On 7/31/24 at 11:23 AM Staff 26 (LPN) confirmed Resident 11 was not assessed to self-administer her/his medications and should have been assessed prior to self-administration of her/his medications.

Based on interview and record review it was determined the facility failed to ensure residents were treated in a dignified manner for 1 of 3 sampled residents (#265) reviewed for dignity. This placed residents at risk for psychosocial harm. Findings include: Resident 265 was admitted to the facility in 12/2023 with diagnoses including depression. A 12/10/23 MDS indicated Resident 265 was cognitively intact. A review of a 2/9/24 Nursing Facility Reported Incident Form revealed Resident 265 had complained about a HIPPA violation committed by Staff 34 (former SSD). A review of a 2/12/24 witness statement from Staff 35 (Activities Director) revealed on 2/7/24 Staff 35 was driving the bus to the bank and heard Staff 34 talking with Resident 265 about the name Resident 265 preferred to go by and Staff 34 asked Resident 265 about her/his finances. When they returned to the facility, Staff 35 brought Resident 265 to her/his room and Resident 265 expressed to Staff 35 how the interaction with Staff 34 had upset her/him. A review of a 2/12/24 witness statement from Resident 265 stated on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to provide rules and regulations governing resident conduct and responsibilities for 1 of 3 sampled residents (#214) reviewed for food. This placed residents at risk for being unformed about rules for resident conduct. Finding include: Resident 214 was admitted to the facility in 6/2024 with diagnoses including stroke and anxiety. A 1/2024 facility Resident Handbook indicated compact refrigerators may be approved for patient use. A 7/16/24 Quarterly MDS indicated Resident 214 was cognitively intact. On 8/2/24 at 11:38 AM Resident 214 stated Staff 14 (Maintenance Director) at one time indicated small refrigerators were allowed in resident rooms and she/he was confused why a request for her/his own refrigerator was recently denied. Resident 214 stated she/he did not receive a copy of a Resident Handbook upon admission to the facility and had no knowledge related to any official rules related to compact refrigerators in resident rooms. On 8/2/24 at 3:49 PM Staff 1 (Administrator in Training) acknowledged at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to obtain information related to advance directives and health care decisions for 2 of 3 sampled residents (#s 12 and 18) reviewed for advance directives. This placed residents at risk for not having their health care decisions honored. Findings include: 1. Resident 12 was admitted to the facility in 3/2024 with a diagnosis of a hip fracture. A 3/28/24 admission 72-hour huddle note indicated Resident 12 had an advance directive and a copy was to be retained for the resident's electronic record. Resident 12's clinical record did not contain her/his advance directive. On 8/1/24 at 1:50 PM Staff 24 (Social Services Director) acknowledged Resident 12's electronic record did not contain an advance directive. 2. Resident 18 was admitted to the facility in 5/2016 with diagnoses including congested heart failure (a disease in which the heart cannot pump enough blood). A 5/30/24 care conference indicated Resident 18 would like assistance formulating an Advanced Directive. A 7/30/24 review of Resident 18's medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to notify family for 2 of 4 sampled residents (#s 4 and 266) reviewed for notification. This placed resident representatives at risk for lack of being informed. Findings include: 1. Resident 4 was admitted to the facility in 1/2024 with a diagnosis of MS (multiple sclerosis: lack of electrical impulses from the brain to the body creating impaired body functions). Resident 4's undated admission Record revealed Witness 6 (Family) was her/his first emergency contact. A 5/21/24 Progress Note revealed Resident 4 had a change in mentation, loose stools and, dark orange urine. The note indicated a RN sent the resident to the hospital for evaluation based on her/his history of decreased kidney function and diagnosis of MS. The note did not indicate Resident 4's emergency contact was notified. On 8/5/24 at 12:51 PM Witness 6 stated she was not notified of Resident 4's 5/2024 hospitalization. On 8/5/24 at 2:11 PM Staff 1 (Administrator) stated Resident 4's emergency contact was not notified of the resident's change of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to maintain resident rights to privacy for 2 of 5 sampled residents (#s 263 and 265) reviewed for dignity and privacy. This placed residents at risk for psychosocial harm. Findings include: 1. Resident 263 was admitted to the facility in 6/2023 with diagnoses including dementia and malnutrition. A 1/16/24 Quarterly MDS indicated Resident 263 was cognitively impaired. A 2/9/24 Discharge Plan of Care indicated Resident 263 was discharged to a memory care facility. On 7/30/24 at 10:15 AM Witness 4 stated unwanted family members entered Resident 263's new memory care facility and she was unaware how they obtained the information regarding Resident 263's discharge location. A 7/31/24 Contacts list for Resident 263 indicated only Witness 4 (Family) and Witness 5 (Family) had access to Resident 263's medical information. On 7/31/24 at 4:18 PM Staff 1 (Administrator in Training) acknowledged she was aware Staff 27 (former Social Service Director) informed family members who were not on Resident 263's contact list…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review it was determined the facility failed to provide a comfortable and homelike environment for 1 of 4 sampled residents (#48) reviewed for ADLS. This placed residents at risk for an unhomelike living environment. Findings include: Resident 48 admitted to the facility in 3/2024 with diagnoses including palliative care and schizophrenia (mental illness). Observations made from 7/29/24 through 8/1/24 on day and evening shifts revealed the following: -7/29/24 at 2:13 PM, fall mats with dried white and yellow debris, brown dirt and a blanket were on top of the fall mats. Washcloths in the resident's sink with a dark brown substance on them. -7/30/24 at 9:10 AM, fall mats still with dried white and yellow debris and what appeared to be pink ice cream or juice. -8/1/24 at 10:55 AM, large towels remained on the floor mat and dirty wash clothes in sink. Staff 19 (CNA) was observed going in and out of the resident's room without grabbing the dirty towels or washcloths. -8/1/24 at 11:02 AM, large towels with yellow and brown debris on the fall…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to ensure residents were free from neglect for 1 of 1 sampled resident (#264) reviewed for accidents. This place residents at risk for neglect. Findings include: Resident 264 admitted to the facility in 4/2024 with diagnoses including leg surgery and chronic pain. An 4/23/24 admission MDS indicated Resident 264 was cognitively intact. A FRI (facility reported incident) indicated on 4/28/24 at 8:00 PM Resident 264 requested tea from Staff 28 (Former CNA). The tea was brought in a hydration mug with a straw, Resident 264 took a drink through the straw and the hot water burnt her/his tongue and roof of her/his mouth. The FRI indicated the administrator was notified on 4/29/24 at 11:00 AM A facility investigation, finalized on 4/29/24, concluded neglect was substantiated as Resident 264 was injured from the hot tea. On 7/31/24 at 11:25 AM Staff 19 (CNA) stated staff training involved not serving the resident really hot beverages, and to make sure the beverages are tempted before serving them to the residents. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to report an allegation of neglect to the appropriate State Agency within two hours for 1 of 1 sampled resident (#264) reviewed for accidents. This placed residents at risk for abuse and neglect. Findings include: Resident 264 admitted to the facility in 4/2024 with diagnoses including leg surgery and chronic pain. An 4/23/24 admission MDS indicated the Resident 264 was cognitively intact. A FRI (facility reported incident) indicated on 4/28/24 at 8:00 PM Resident 264 requested tea from Staff 28 (Former CNA). The tea was brought in a hydration mug with a straw, Resident 264 took a drink through the straw and the hot water burnt her/his tongue and roof of her/his mouth. The FRI indicated the administrator was notified on 4/29/24 at 11:00 AM A facility investigation, finalized on 4/29/24, concluded neglect was substantiated as Resident 264 was injured from the hot tea. On 8/1/24 at 2:40 PM Staff 6 (LPN-Resident Care Manager) acknowledged he was aware of the incident on 4/28/24 at 8:00 PM but did not send the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review it was determined the facility failed to implement a comprehensive care plan for 3 of 9 sampled residents (#s 2, 165, and 266) reviewed for medications, accidents, and hospice. This placed residents at risk for unmet care needs. Finding include: 1. Resident 2 was admitted to the facility in 2/2024 with diagnoses including diabetes and dementia. The 6/5/24 revised care plan indicated there was no initial care plan for Resident 2's diabetic goals and interventions. The 6/30/24 through 7/30/24 Order Review History Report indicated Resident 2 had multiple orders for diabetic care which started on 2/26/24 including nail care by nursing. The 7/2024 Diabetic Administration Record indicated Resident 2 received insulin each morning. On 8/1/24 at approximately 1:00 PM Staff 23 (LPN-Resident Care Manager) acknowledged Resident 2 lacked a diabetic care plan. 2. Resident 266 was admitted to the facility in 7/2024 with diagnoses including dementia and history of UTIs. A 7/16/24 Elopement Risk Evaluation identified Resident 266 as high risk for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review it was determined the facility failed to provide care and services to maintain good grooming and hygiene for 2 of 4 sampled residents (#s 48 and 164) reviewed for ADLs. This placed residents at risk for unmet needs. Findings include: 1. Resident 48 was admitted to the facility in 3/2024 with diagnoses including hospice services and chronic bed confinement. The 3/11/24 care plan indicated Resident 48 was totally dependent on staff for personal hygiene care and dressing. On 7/29/24 at 2:32 PM Resident 48 was observed to have greasy, uncombed hair, long jagged fingernails with brown debris underneath, food on her/his face and in her/his mouth, facial hair, and a shirt with dried dark brown debris. On 7/31/24 at 11:06 AM Witness 9 (Caregiver) stated Resident 48 did not receive the ADLS care she/he needed. Witness 9 stated Resident 48 needed staff to wash her/his hair, trim and clean her/his nails, shave her/him daily, lotion her/his dry feet, and put a clean shirt on the resident daily. Witness 9 stated she completed the ADL care while…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, and record review it was determined the facility failed to investigate a new facility acquired pressure ulcer for 1 of 2 sampled residents (#20) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers. Findings include: Resident 20 was admitted to the facility in 2/2020 with diagnoses including hemiplegia (paralysis of one side of the body) of the left nondominant side. A 7/29/24 review of Resident 20's medical record revealed a 2/9/24 facility acquired stage 3 pressure ulcer (a full thickness tissue loss wound cause by pressure) to her/his sacrococcygel (tailbone). A review of a 7/29/24 Wound Evaluation revealed a stage 3 wound on Resident 20's sacrococcygel which measured 0.76 cm by 0.5 cm. On 8/1/24 at 12:28 PM Staff 37 (Regional Nurse Consultant) stated there was no investigation completed for Resident 20's 2/9/24 facility acquired pressure ulcer to her/his sacrococcygel. On 8/2/24 at 10:53 AM Resident 20 was observed to have an open stage 3 wound on her/his right upper buttock near the sacrococcygel area. Resident 20's wound…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined the facility failed to ensure windows on the first floor locked for 1 of 1 sampled resident (#163) reviewed for accidents. This placed residents at risk for an unsecured environment. Findings include: 1. Resident 163 was admitted to the facility in 5/2024 with a diagnosis of spinal (neck) surgery. A Census report from 5/29/24 through 6/3/24 revealed Resident 163 resided in room [ROOM NUMBER] and 205. While in both rooms, Resident 163 was in a bed located by a window. On 7/29/24 at 12:30 PM Witness 7 (Complainant) stated Resident 163's windows were able to be opened even when the locking device was utilized. On 7/31/24 at 7:50 AM Staff 14 (Maintenance) verified the windows in both 201 and 205 had broken locking devices and were easily opened. Staff 14 stated he was not aware of the issue.

Based on interview and record review it was determined the facility failed to provide adequate care for 2 of 3 sampled residents (#s 4 and 266) reviewed for UTIs. This placed residents at risk for UTIs. 1. Resident 4 was admitted to the facility in 1/2024 with a diagnosis of MS (multiple sclerosis: lack of electrical impulses from the brain to the body creating impaired body functions). A 1/26/24 admission MDS revealed Resident 4 had a urinary catheter (medical tubing inserted in the bladder to drain urine) and staff were to ensure the urine flowed to prevent UTIs. A 7/2024 TAR and associated Progress Notes revealed staff were to flush (instill sterile fluid to prevent the tubing from clogging) Resident 4's urinary catheter on Monday, Wednesday, and Fridays. From 7/1/24 through 7/19/24 staff had eight opportunities to flush the catheter. On five occasions the flush was not completed due to lack of sterile solution or did not occur. On 8/5/24 at 12:51 PM Witness 6 (Family) stated Resident 4 was susceptible to UTIs and staff were to flush the catheter to ensure good urine flow. One…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review it was determined the facility failed to ensure residents' respiratory equipment was maintained for 3 of 6 sampled residents (#s 11, 164 and 267) reviewed for respiratory, ADLs and dialysis. This placed residents at risk for respiratory issues. Findings include: 1. Resident 11 was admitted to the facility in 8/2014 with diagnoses including COPD (lung disease). The facility's revised Policy and Procedure dated 11/2011 indicated the following: - after a nebulizer (a compressor which turns liquid medications into a fine mist which is inhaled through a mouthpiece) treatment the nebulizer container should be removed, rinsed with fresh tap water, and dried on a clean paper towel or gauze sponge -reconnect to the administration set-up when air dried -Take care not to contaminate the internal nebulizer tubes -Wipe the mouthpiece with a damp paper towel or gauze sponge -Store the circuit in a plastic bag -Discard the administration set-up every seven days Observations from 7/29/24 through 8/5/24 on day and evening shifts revealed Resident 11…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to evaluate and provide person centered interventions for 1 of 1 sampled resident (#51) reviewed for mood and behavior. This place residents at risk for re-traumatization. Finding include: Resident 51 was admitted to the facility in 5/2024 with diagnoses including PTSD (Post Traumatic Stress Disorder) and anxiety. A 5/25/24 care plan for trauma indicated Resident 51 had PTSD and to ask permission to approach the resident during activities such as personal care, delivering medication and combing/brushing of hair (which were not mentioned as triggers by Resident 51). An activity intervention included not to touch Resident 51 when she/he was sleeping. On 7/29/24 at 12:14 PM Resident 51 stated she/he had disturbing nightmares related to combat and staff were not aware of how to assist with her/his PTSD. Staff 51 stated she/he had requested counseling but there was no followup to the request. On 8/2/24 at 9:22 AM Staff 15 (CNA) confirmed Resident 51 had one to three disruptive nightmares weekly and believed other…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to complete nurse aide performance reviews every twelve months for 3 of 5 sampled CNAs (#s 3, 4, and 7) reviewed for staffing. Findings include: Review of 5/23/24 through 7/2024 training documents revealed the following: -Staff 3's last performance review was in 2022. -Staff 4's last performance review was in not in her record and her hire date was 7/18/22. -Staff 7's last performance review was in 2022. On 8/1/24 at 8:30 AM Staff 2 (DNS) verified Staff #s 3, 4, and 7 did not have their annual performance reviews.

Based on interview and record review it was determined the facility failed to provide monitoring for anticoagulant medications for 1 of 5 sampled residents (#18) reviewed for medications. This placed residents at risk for unidentified medication adverse side effects. Findings include: Resident 18 was admitted to the facility in 5/2016 with diagnoses including atrial fibrillation (an irregular heartbeat). A review of Resident 18's physician orders revealed a 7/11/22 order for apixaban, an anticoagulant medication (a blood thinner). A 7/31/24 review of Resident 18's care plan revealed no evidence of a care plan for anticoagulant medication. An 8/2/24 review of Resident 18's medical record revealed no evidence of monitoring for adverse side effects from anticoagulant medications. On 8/2/24 at 1:52 PM Staff 23 (LPN Resident Care Manager) Stated Resident 18 took an anticoagulant medication, apixaban, and should have been monitored for adverse side effects such as bleeding and bruising. Staff 23 confirmed Resident 18 was not monitored for adverse side effects from anticoagulant…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to attempt a gradual dose reduction and montior for psychotropic medications for 2 of 5 sampled residents (#s 12 and 15) reviewed for medications. this placed residents at risk for adverse medication reactions. Findings include: 1. Resident 12 admitted to the facility in 3/2024 with diagnoses including anxiety disorder and depression. A review of 7/2024 MAR revealed Resident 12 was administered Lexapro (antidepressant), Trazodone (antidepressant), Xanax (antianxiety) and Buspirone (antianxiety). A review of the 7/2024 behavior monitors revealed interventions but did not list triggers for the resident's behaviors. On 8/1/24 at 10:46 AM Staff 15 (CNA) stated Resident 12 had triggers which made her/his anxiety worse. Staff 15 stated her/his triggers were when therapy comes into her/his room without some notification, if her/his call light was not answered timely, and if she/he feels lonely. Staff 15 stated there were more, but those were the main triggers. On 8/2/24 at 2:24 PM Staff 6 (LPN-Resident Care Manager)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview it was determined the facility failed to ensure a treatment cart was locked for 1 of 2 units (Shasta Unit). This placed residents at risk for injury. Findings include: On 7/30/24 at 2:23 PM to 2:43 PM a Shasta Unit treatment cart was observed to be unlocked. The cart was in an alcove and one wall of the alcove blocked the view of the cart from the nurse's station. Nursing staff and therapy staff walked by the cart at 2:28 PM, 2:33 PM, and 2:36 PM and did not lock the cart. On 7/30/24 at 2:43 PM Staff 31 (LPN) stated she just came on shift, was not aware the treatment cart was unlocked, and it should be locked.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to prepare therapeutic diets for 1 of 3 sampled residents (#267) reviewed for nutrition. This placed residents at risk for compromised nutrition. Finding include: The 7/31/24 posted lunch menu included: Smoke Sausage, Lyonnaise Potatoes and Steamed Cabbage. A Diet Spread Sheet for the 7/31/24 menu indicated residents with a limited salt, phosphate (dietary nutrient) or potassium (dietary nutrient) diet were to be served roasted pork in place of the sausage. 1. Resident 267 was admitted to the facility in 7/2024 with diagnoses including kidney failure and hip fracture. A 7/25/24 physician Order Details indicated Resident 267 was to receive a diet limited in salt, potassium and phosphate. On 8/1/24 at 10:29 AM Resident 267 stated on 7/31/24 the menu option provided for lunch included sausage (a food high in salt and phosphates) which was delivered. Resident 267 stated she/he ate the sausage because it was provided and trusted the facility to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide food according to residents' meal preferences for 2 of 5 sampled residents (#s 1 and 214) reviewed for food. This placed residents at risk for lack of meal satisfaction. Finding include: The 4/23/24 Resident Council notes indicated residents had concerns about meal preferences that were not provided as requested including: -Residents who asked CNAs for an different menu selection after a meal was delivered often did not receive any replacement. -Residents' meal plates did not contain the foods which were selected by the residents. The 5/21/24 and 6/26/24 Resident Council notes indicated residents continued to have concerns about meal preferences that were not provided as requested and the dietary department was aware. 1. Resident 1 was admitted to the facility in 11/2016 with diagnoses including anemia and acute kidney failure. On 7/30/24 at 7:50 AM Resident 1 stated she/he often did not receive what she/he ordered for meals. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to ensure residents understood the meaning of an arbitration agreement (disputes are resolved with a neutral party and not in court) for 3 of 3 sampled residents (#s 9, 53, and 165) reviewed for arbitration. This placed residents at risk for being uninformed of their legal rights. Findings include: 1. Resident 9 was admitted to the facility in 5/2024 with a diagnosis of Parkinson's disease. A 5/14/24 admission MDS revealed Resident 9 was cognitively intact. A Patient and Facility Arbitration Agreement revealed Resident 9 signed the agreement on 5/9/24. On 7/31/24 at 12:15 PM Resident 9 stated she/he remembered signing a large number of papers at the time of her/his admission but did not recall anything about arbitration. On 7/31/24 at 12:25 PM Staff 9 (Admissions) stated she reviewed the arbitration agreement when she had a resident or resident representative sign the admission paperwork. Staff 9 stated she did not follow-up with residents after they signed the papers to ensure they understood what was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to ensure antibiotics were indicated for 1 of 3 sampled residents (#4) reviewed for UTIs. This placed residents at risk for developing drug resistant organisms. Findings include: Resident 4 was admitted to the facility in 1/2024 with a diagnosis of MS (multiple sclerosis: lack of electrical impulses from the brain to the body creating impaired body functions). 3/2024 and 4/2024 MARs revealed Resident 4 was administered antibiotics for a possible UTI from 3/30/24 through 4/5/24. A 3/31/24 Lab Results form revealed Resident 4's UA did not require a culture. Resident 4's clinical record revealed there was no rationale for the continuation of antibiotics when there was no indication Resident 4 had a UTI. On 8/2/24 at 10:17 AM Staff 6 (LPN Resident Care Manager) verified there was no rationale documented in Resident 4's clinical record to indicate the benefit of the continuation of antibiotics outweighed the risks.

Based on interview and record review it was determined the facility failed to provide immunizations, consents and declinations for 3 of 5 sampled residents (#s 3, 20, and 22) reviewed for immunizations. This placed residents at risk for infections. Findings include: 1. Resident 3 was admitted to the facility in 12/2018 with diagnoses including congestive heart failure (a condition in which the heart cannot pump enough blood). An 8/5/44 review of Resident 3's immunizations revealed she/he received the COVID 19 vaccination on 12/23/20, 1/13/21 and 10/19/21, no evidence of COVID 19 boosters were administered after 10/19/21. An 8/5/24 review of Resident 3's medical record revealed no evidence of signed consents for the COVID 19 vaccinations received on 12/23/20, 1/13/21 and 10/19/21 and no evidence any COVID 19 booster vaccinations were offered, administered or declined after 10/19/21. On 8/5/24 at 10:35 AM Staff 1 (Administrator in Training) stated the vaccination offerings, consents and declinations were kept in a binder. Staff 1 was unable to locate Resident 3's consents for the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview it was determined the facility failed to ensure a call light was accessible for 2 of 3 sampled residents (#s 20 and 48) reviewed for hospice and pressure ulcers. This placed resident at risk for unmet needs. Findings include: 1. Resident 20 was admitted to the facility in 2/2020 with diagnoses including hemiplegia (paralysis of one side of the body) of the left nondominant side. On 7/31/24 at 11:12 AM Resident 20 was observed in bed, her/his call light hung off the left side of the bed between the mattress and side rail towards the floor. Resident 20 had softly yelled for help whenever a staff member walked past her/his room. On 7/31/24 between 11:12 AM and 11:26 AM multiple staff were observed to have walked past Resident 20's room without stopping or assisting Resident 20. On 7/31/24 at 11:26 AM Staff 33 (Housekeeping Manager) was observed cleaning Resident 20's door. Resident 20 asked for help to scratch her/his back and Staff 33 stated she could not assist but would get assistance. On 7/31/24 between 11:26 AM and 11:48 AM multiple staff were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to honor the right to receive visitors of his or her choice for 1 of 3 sampled residents (#4) reviewed for visitation. This placed residents at risk for lack of visitation. Findings include: Resident 4 was admitted to the facility in 6/2023 with diagnoses including pressure ulcers. Review of a letter dated 10/10/23 revealed Witness 10 (Family Member) requested the facility not allow Witness 3 (Complainant) or Witness 7 (Friend) to visit the resident and to notify Witness 10 if anyone asked about the resident. Review of a MDS assessment dated [DATE] revealed the resident was cognitively intact. Review of a progress note dated 11/11/23 at 4:34 PM revealed the resident had visitors which included Witness 3. Staff had been instructed by the resident's responsible party Witness 3 was not allowed contact with the resident. The resident's visitors were asked to leave the facility, said good bye to the resident and left peacefully. Review of a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to ensure sufficient nursing staffing on a 24-hour basis for 1 of 1 building reviewed for staffing. This placed residents at risk for unmet care needs. Findings include: Review of Direct Care Staff Daily Reports from 3/1/23 through 3/31/23, 4/1/23 through 4/30/23 and 7/1/23 through 7/31/23 revealed the facility was understaffed for CNAs 29 of 31 days in 3/2023, 15 of 30 days in 4/2023 and 9 of 30 days in 7/2023 or 53 of the 91 days reviewed. Resident Council Notes were reviewed from 3/2023, 4/2023 and 7/2023 and included the following: *3/22/23: CNAs would come in and write on the white boards (daily care staff) and residents would not see the CNAs again during the shift. -Trash cans in resident bathrooms were hardly ever checked and CNAs were to empty them on every shift. -Agency CNAs never brought snack carts around, even some of the long term CNAs did not bring it around. The snacks were important to diabetic residents especially at bedtime. -CNAs were not asking residents regular daily questions related…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to provide care and services to ensure the resident's right to be free from abuse was honored for 1 of 1 sampled resident (#13) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 13 admitted to the facility in 2019 with diagnoses including depression and anxiety. A facility Incident Report dated 2/4/23 indicated Resident 13 reported Staff 17 (CNA) treated her/him badly and attempted to change the resident's brief without permission. The resident indicated Staff 17 and Staff 16 came into the room. Staff 17 forcefully pulled her/his covers back and put her hands on the resident to undo her/his brief. Resident 13 told the CNA to stop and tried to push the CNA away. The resident reported Staff 17 said she/he stunk and would not listen when the resident told her to stop. The resident screamed at Staff 17. The nurse came in and pulled the CNA off the resident and had the CNA leave the room. The facility Incident Report dated 2/4/23 also included the following: -On 2/8/23 Witness…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to provide follow-up documentation on advance directives for 4 of 4 sampled residents (#s 28, 50, 63 and 67) reviewed for advanced directive. This placed residents at risk for being uninformed of their medical rights. Findings include: The facility's Advanced Directive policy dated 1/5/00 indicated A copy of the advance directive will be filed in the Advance Directive section of resident's charts. 1. Resident 28 was admitted to the facility in 2019 with diagnoses including kidney disease and a leg amputation. The resident's 72 Hour Huddle document dated 11/19/19 indicated yes, a copy of the Advance Directive is to be obtained for the medical record. No advance directive could be located in Resident 28's medical record. On 1/30/20 at 8:20 AM Staff 8 (Transitions Coordinator) stated when she completed the 72 Hour Huddle document the choice box indicated yes or no the resident had an advance directive. Staff 8 stated she marked yes which indicated she gave the resident a copy of the advance directive. Staff 8…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined the facility failed to provide a clean and homelike environment for 9 of 10 sampled bathrooms in resident rooms (#s 513, 515, 520, 522, 528, 530, 532, 533 and 534) and a clean floor in room [ROOM NUMBER] reviewed for environment. This placed residents at risk for an unhomelike environment. Findings include: 1. On 1/27/20 during observations on the 500 hall of the facility a strong scent of urine was detected. The smell was strong and did not dissipate during the one to two hour timeframe the surveyor was in the hallway visiting rooms. The smell was strongest inside the residents' rooms and near the bathroom doors. On 1/27/20 at 4:15 PM Resident 46 revealed she/he was aware of the strong urine smell coming from the bathroom. The resident stated the toilet was too short and the commode which was over the toilet allowed leakage of urine to spill onto the floor. The resident stated staff usually put a rolled-up towel on the floor to sop up the excess but the urine…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review it was determined the facility failed to ensure residents received the necessary services to maintain grooming for 1 of 1 sampled resident (#66) reviewed for ADLs. This placed residents at risk for unmet grooming needs. Findings include: Resident 66 admitted to the facility in 2019 with diagnoses including stroke. The 11/8/19 ADL Care Plan indicated the resident required physical assistance from one staff for personal hygiene. On 1/27/20 at 4:08 PM Resident 66 was observed to have visible growth of hair to her/his face. On 1/27/20 at 4:08 PM Resident 66 stated she/he had asked staff to shave her/him but indicated staff stated they were too busy to shave her/him. On 1/29/20 at 12:10 PM Resident 66 had not been shaved. Staff 9 (LPN) was notified the resident would like to be shaved and stated she/he would let the resident's CNA know to shave the resident. On 1/29/20 at 12:55 PM Staff 13 (CNA) stated Staff 9 asked him to shave the resident and stated he would shave her/him after lunch. On 1/29/20 at 4:11 PM Staff 5 (RCM/LPN) was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to provide restorative assistance services for a contracture for 1 of 2 sampled residents (#42) reviewed for range of motion. Findings include: Resident 42 was admitted to the facility in 2017 with diagnoses including dementia and a brain injury. A Therapy RA Referral Form dated 11/21/19 instructed staff to provide Resident 42 with range of motion (ROM) to the resident's shoulder, neck stretching and to maintain grip strength twice a week. From 1/27/20 though 1/31/20 multiple observations of Resident 42 revealed her/his head was bent sideways to her/his right shoulder and without changing position. The RA Daily Sheets for all residents who were to receive restorative aide services revealed Resident 42 only received range of motion (ROM) on 11/21/19 and 1/28/20. Resident 42's Annual MDS dated [DATE] indicated the resident had limited range of motion (ROM) to her/his upper extremity on one side. Resident 42's comprehensive care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.